Additional data in the debate on stage I non-small cell lung cancer: surgery versus stereotactic ablative radiotherapy

Lobectomy has been the standard of care for patients with early stage non-small cell lung cancer (NSCLC), resulting in nearly universal local control and excellent overall survival. However, up to one-quarter of early stage patients are unable to undergo or refuse definitive resection. With the increasing adoption of stereotactic ablative radiotherapy (SABR) over conventionally fractionated radiotherapy among medical inoperable patients, tumor control and overall survival rates in this population have significantly improved. Trials demonstrating excellent outcomes among both medically inoperable and medical operable patients with stage I NSCLC have spurred interest in comparisons between surgery and SABR. The recent publication of the randomized STARS and ROSEL trials demonstrated fewer toxicities and an improvement in overall survival among patients treated with SABR compared with surgery. Based on these trials and retrospective comparisons between the modalities, definitive SABR now more firmly appears to be a viable first-line option for treating patients with operable stage I NSCLC.